Method of performing port off-pump beating heart coronary artery bypass surgery

ABSTRACT

A method for performing through-port off-pump beating heart coronary artery bypass surgery is provided. A port device is positioned in the chest wall and directed as necessary. A heart stabilizer is coupled to the port, and operated to apply a compressive force against the heart wall surrounding a location the required bypass such that the location is substantially immobilized. An instrument stabilizer includes a cannula which is inserted through a hole in the chest cavity, and the distal tip of the cannula is located adjacent the surgical site. The instrument stabilizer dampens movement of a surgical instrument, e.g., a scalpel or needle holder, extended therethrough. Once the bypass procedure is complete, the instruments, heart stabilizer, instrument stabilizers, and port are removed from the body of the patient.

This application is a continuation-in-part of U.S. Ser. No. 09/686,696,filed Oct. 11, 2000 and entitled “Port Device for Port Off-Pump BeatingHeart Coronary Artery Bypass Surgery System”, and U.S. Ser. No.09/686,530, filed Oct. 11, 2000 and entitled “Port Off-Pump BeatingHeart Coronary Artery Bypass Heart Stabilization System”, each which ishereby incorporated by reference herein in its entirety.

BACKGROUND OF THE INVENTION

1. Field of the Invention

This invention relates broadly to surgical methods. More particularly,this invention relates to a method for performing coronary artery bypasssurgery.

2. State of the Art

Substantially all coronary artery bypass (CAB) procedures are performedvia an open chest method. In the procedure, the chest is opened throughan, incision in the middle of the chest, called a sternotomy, and theribs are retracted and held stably open with a retractor. This providesa sufficient amount of access to the heart. The heart is then arrestedand the blood flow is rerouted through a heart-lung machine. The bypassprocedure is then performed, and once complete, the heart is thenrestarted and blood is permitted to flow through the “bypass”. Whilethis procedure is the norm, it is far from desirable. First, arrestingthe heart is a dangerous procedure and can lead to serious complicationsand even death. Second, the procedure requires a sternotomy, which ispainful and traumatic. Because of this incision the recovery time isrelatively long and the patient is left with a permanent large scar.

More recently, some surgeons have performed coronary artery bypasssurgery on a beating heart. The chest is opened via a sternotomy andretracted. Using a device called a heart stabilizer, the surgical siteon the heart is essentially immobilized for suturing. The heartstabilizer is typically anchored to the retractors which are in turnanchored to the walls of the chest at the site of the incision. Directaccess to the surgical site as well as immobilization of the surgicalsite are key to the surgery. These factors allow the surgeon to performa suture or other operation with precision. While the methodology iseffective and eliminates the potential complications of arresting theheart, the drawbacks associated with the sternotomy remain.

It has recently been proposed by others to perform a closed chest bypassprocedure on the beating heart. However, the proposal has not beenfollowed by any concrete directions on how to satisfactorily perform theprocedure. In addition, the inventors of the present application haverecognized that the closed chest procedure has a number of hurdles toovercome. First, it is necessary to stabilize the heart such that thelocation requiring the bypass does not significantly move during theprocedure. Second, while open chest procedure are accompanied by aretractor and instrument supporting framework, in a closed chestprocedure, there is no such framework for holding the instrumentsrequired for the procedure. In addition, there is no suitable stableport device adapted to securely support instruments passingtherethrough. Third, when performing any surgery through a port, theinstruments used to work at the surgical site are relatively longcompared to open chest instruments. The distance from the surgeons'shand to the tip of the instrument where the work is being performed canbe many times greater than in conventional surgery. This increase inlength amplifies normal hand tremor and any errors in motion.

SUMMARY OF THE INVENTION

It is therefore an object of the invention to provide a less traumaticinstrument access to the surgical site.

It is another object of the invention to provide a port device which iseasy to insert into the body.

It is a further object of the invention to provide a port device with ahigh degree of stability.

It is an additional object of the invention to provide a heartstabilizer which can be inserted through the port device and which isadapted to stabilize a portion of a beating heart such that coronaryartery bypass surgery can be performed on the portion of the heart.

It is also an additional object of the invention to provide a heartstabilizer which can be manipulated via a proximal handle external ofthe port device.

It is still another object of the invention to provide an instrumentstabilization system which minimizes unwanted motion of the tips ofinstrument performing the procedure.

It is still a further object of the invention to provide an instrumentstabilization system which can be coupled to the port device.

It is yet another object of the invention to provide a system ofcomponents which cohesively operates together to facilitate portoff-pump coronary artery bypass surgery on a beating heart.

It is yet a further object of the invention to provide a method ofperforming port off-pump coronary artery bypass surgery on a beatingheart.

In accord with these objects, which will be discussed in detail below, asystem for performing port off-pump beating heart coronary artery bypasssurgery is provided. The system includes three primary subsystems: aport device, a heart stabilizer, and an instrument stabilizer.

The port device is insertable between the ribs of the patient andfunctions as an entry way for each instrument necessary for theprocedure, e.g., optics, graspers, needle holders, suction/irrigationtubes, stabilizers. According to a preferred aspect of the invention,the port device includes a tubular body having proximal and distalportions and intended to be inserted through a pair of ribs in a chestwall of a patient. The proximal portion of the tubular body includes aplurality of thread grooves extending at least partially about acircumference of the body as well as a means to permit the heartstabilizer, the instrument stabilizer, or another device to bereleasably secured to the port. The distal portion of the tubular bodyis coupled to a swivel adapted to be moved between a first orientationin which the swivel extends in substantially a same direction as thebody, and a second orientation at an angle relative to, and preferablysubstantially perpendicular to, the first orientation.

According to certain embodiments of the port device, a washer ispositioned on the body between the swivel and the proximal portion ofthe body, and a locknut is threadably engaged in the thread grooves.When the tubular body is inserted between two ribs in the chest wall ofthe patient, the swivel is then opened into the second orientation andthe washer is moved along the body to position the chest wall betweenthe swivel and the washer. The locknut is then tightened about the bodyto clamp the washer against the chest wall and stably secure the tubularbody within the chest wall.

According to other embodiments of the port device, a platform movablealong the length of the port body includes adjustable legs and feet. Thelegs are adjusted such that the feet contact the chest wall and clampthe chest wall between the feet and the swivel. In addition, the legsmay be adjusted to provide the body in a desired angle relative to thechest wall. According to preferred aspects of these embodiments of theport device, the platform may be ratcheted relative to the port body andthe feet may be ratcheted relative to the platform to permit rapidadjustment of the port relative to the patient. In addition, preferablythree legs are provided to aid in stability of the port on the body ofthe patient.

According to various aspects of the several embodiments of the port, theport may include a thread system adapted to permit quick locking of thelocknut against the washer or the platform along the body, one or twoswivels, and/or a ball joint permitting angular orientation of the portto permit the port to be directed toward a desired location such as thesurgical site. In addition, the swivel or swivels may be spring biasedto move from the first orientation to the second orientation, or anintroducer device may be provided to mechanically move the swivel orswivels between the first and second orientations.

The heart stabilizer preferably includes a shaft and two jointed armscoupled to a distal end of the shaft. At the end of each arm is arotatable foot adapted to be angled relative to the heart wall contourand apply pressure against the wall of the heart to effectivelyeliminate motion of the heart wall between the feet. The stabilizer isadapted to provide a stabilized area sufficiently large to allow anaccurate anastomosis to be performed. According to preferred aspects ofthe invention, the stabilizer is particularly adapted to be collapsible(foldable) to be inserted through the port device and lockedlongitudinally relative thereto. The stabilizer is also preferablyadapted to be automatically deployed into its final configuration byrelease of a lock actuated at a proximal portion of the stabilizerextending outside the port. In addition, the stabilizer is adapted toautomatically fold when being pulled back through the port.

According to various embodiments of the heart stabilizer, the feet ofthe stabilizer may be further adapted to facilitate immobilization ofthe heart wall between the feet. In addition to compressive forces, thefeet may apply suction, chemical agents, electrical current, or thermalcooling to enhance the heart wall immobilization.

According to another aspect of the invention, the instrument stabilizeris adapted to minimize unwanted motion at the distal end of a surgicalinstrument extending through the instrument stabilizer by applying abiasing force to the tip of the instrument. The instrument stabilizermay be coupled to a port or may be coupled directly to a patient, e.g.,with sutures. According to a preferred embodiment, the instrumentstabilizer preferably includes a cannula (tubular member) through whichan instrument can extend, and a preferably distal contact element, e.g.,an O-ring or a tapered diameter of the cannula, adapted to be in a closefit about the instrument and which provides proximal and distalstabilization. The instrument stabilizer also includes a proximalhousing that includes a mechanism which applies a stabilizing force tothe tubular member for movements transverse to the axis of the cannula.The mechanism which applies the force may be, by way of example, one ormore of elastic bands, springs, struts, etc. When the surgicalinstrument is extended through the cannula and contacts the contactelement, movement of the cannula and consequently the surgicalinstrument is damped by the stabilization force on the cannula.According to another embodiment, a mechanism which applies astabilization force may be attached to a shaft of another instrument,e.g., the shaft of the heart stabilizer. According to yet anotherembodiment, the cannula is provided with a valve to permit theinstrument stabilizer to be used for surgical procedures requiringinsufflation of the body cavity in which the instrument stabilizer isinserted.

A stabilizer swivel may be used with an instrument stabilizer toangularly direct the cannula of the instrument stabilizer relative tothe body of the patient. The stabilizer swivel includes upper and lowerwedges rotatably coupled to each. Each wedge includes an opening throughwhich the cannula may be extended. Relative rotational configurations ofthe wedges operate to orient the opening of the upper wedge relative tothe lower wedge and the surface on which the lower wedge is seated.

The above-described components together define a surgical system forperforming port off-pump beating heart coronary artery bypass surgery.According to a preferred method which utilizes the system, a port deviceis stably positioned, e.g. clamped, in the chest wall and directed asnecessary for operation on the heart wall. A heart stabilizer is coupledto the port, and operated to apply a compressive force against the heartwall surrounding a location of the required bypass such that thelocation is substantially immobilized. An instrument stabilizer isinserted through a puncture hole in the chest cavity, and the distal tipof the cannula of the stabilizer is located adjacent to the surgicalsite. A first surgical instrument, e.g., a scalpel or needle holder, ispassed through the cannula and operated to perform at least a portion ofthe procedure. If other surgical instruments are required, the firstinstrument may be removed and other instruments may be extendedtherethrough. Alternatively, an instrument stabilizer may be providedfor each instrument. Once the bypass procedure is complete, theinstruments and instrument stabilizers are removed from the locus of thesurgery, and the heart stabilizer is also removed through its port.Then, the clamping forces on the port is loosened and the port iswithdrawn from the chest wall. Finally, the incision and puncture holesin which the port and instrument stabilizer were located are closed.This method eliminates the need for many open heart procedures, as wellas the need to stop the heart.

Additional objects and advantages of the invention will become apparentto those skilled in the art upon reference to the detailed descriptiontaken in conjunction with the provided figures.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a bottom perspective view of a first embodiment of a portdevice according to the invention, shown with the swivels in a closedconfiguration;

FIG. 2 is a partially disassembled top perspective view of a swivel andpivot axles according to the first embodiment of a port device accordingto the invention;

FIG. 3 is a bottom perspective view of the first embodiment of the portdevice according to the invention, shown with the swivels in a partlyopen configuration;

FIG. 4 is a top perspective view of the first embodiment of the portdevice according to the invention, shown with the swivels in an openconfiguration;

FIG. 5 is a side elevation view of the first embodiment of the portdevice according to the invention, shown with the swivels in an openconfiguration, and the port body angled relative to the washer;

FIG. 6 is a top perspective view of a locking nut according to a firstembodiment of a port device according to the invention;

FIG. 7 is a front perspective view of an introducer according to theinvention;

FIG. 8 is an exploded perspective view of the introducer of FIG. 7;

FIG. 9 is an enlarged perspective view of the distal end of theintroducer of FIG. 7;

FIG. 10 is a side perspective view of introducer coupled to the portdevice according to the invention, with the swivels shown in an openconfiguration;

FIG. 11 is a view similar to FIG. 10 with the swivels shown in a partlyclosed configuration;

FIG. 12 is a view similar to FIG. 10 with the swivels shown in a closedconfiguration;

FIG. 13 is an exploded side perspective view of a second embodiment of aport device according to the invention, with the swivel shown in aclosed configuration;

FIG. 14 is a top perspective view of the second embodiment of the portdevice, with the swivel shown in an open configuration;

FIG. 15 is a side perspective of a second embodiment of the port deviceshown inserted in body tissue and between ribs of a patient;

FIG. 16 is a side perspective view of a first embodiment of a heartstabilizer device according to the invention;

FIG. 17 is an exploded perspective view of the shaft lock of the heartstabilizer device of FIG. 16;

FIG. 18 is a perspective view of the stabilizing mechanism at the distalend of the heart stabilizer device of FIG. 16;

FIG. 19 is an exploded perspective view of the stabilizing assembly ofthe heart stabilizer device of FIG. 16;

FIG. 20 is a broken longitudinal section view of the shoulders and upperarms of the stabilizing assembly of the heart stabilizer device of FIG.16 shown in a closed position;

FIG. 21 is a broken bottom perspective view of the stabilizing assemblyof the heart stabilizer device of FIG. 16 shown in a closed position anda port device according to the invention.

FIG. 22 is a perspective view of the heart stabilizer device, with thestabilizing assembly shown in a folded configuration and being insertedinto the port device of the invention;

FIG. 23 is a perspective view of the heart stabilizer device, with thestabilizing assembly shown in a folded configuration and being insertedinto the port device of the invention and also with a shaft lock beingcoupled to the port device;

FIG. 24 is a perspective view of the heart stabilizer device, with thestabilizing assembly shown in a folded configuration and being extendedthrough the port device of the invention;

FIG. 25 is a partial longitudinal section view of the stabilizingassembly in a partially open first configuration;

FIG. 26 is a partial longitudinal section view of the stabilizingassembly in a partially open second configuration more open that thefirst configuration;

FIG. 27 is a perspective view of the heart stabilizer device, with thestabilizing assembly shown extended through the port device of theinvention and in the second configuration;

FIG. 28 is a partial longitudinal section view of the stabilizingassembly in a third configuration more open that the secondconfiguration and in which the lock pins engage the lower arm cam locks;

FIG. 29 is a partial longitudinal section view of the stabilizingassembly in a fully open fourth configuration in which the lower armsare locked relative to the upper arms;

FIG. 30 is a perspective view of the heart stabilizer device, with thestabilizing assembly shown extended through the port device of theinvention and in the fully open fourth configuration;

FIG. 31 is a perspective view of a second embodiment of a portintroducer according to the invention;

FIG. 32 is a perspective view of a third embodiment of a port deviceaccording to the invention;

FIG. 33 is a perspective view of a fourth embodiment of a port deviceaccording to the invention;

FIG. 34 is a partial section view across line 34—34 in FIG. 33 of thetubular body of the fourth embodiment of the port device of theinvention;

FIG. 35 is a lower perspective view of a first embodiment of aninstrument stabilizer according to the invention;

FIG. 36 is a top perspective view of the first embodiment of theinstrument stabilizer;

FIG. 37 is an exploded view of the first embodiment of the instrumentstabilizer.

FIG. 38 is an exploded perspective view of the first embodiment of theinstrument stabilizer aligned with a port device according to theinvention;

FIG. 39 is a perspective view of the first embodiment of the instrumentstabilizer coupled to a port device, and a surgical instrument extendingthrough the instrument stabilizer and port device;

FIG. 40 is a lower perspective view of a second embodiment of theinstrument stabilizer of the invention, shown in with a trocar extendingwithin the stabilizer;

FIG. 41 is an upper perspective view of the second embodiment of theinstrument stabilizer of the invention;

FIG. 42 is an exploded view of a third embodiment of the instrumentstabilizer of the invention;

FIG. 43 is a longitudinal section view of a fourth embodiment of theinstrument stabilizer of the invention;

FIG. 44 is an exploded bottom perspective view of the fourth embodimentof the instrument stabilizer of the invention;

FIG. 45 is an exploded top perspective view of the fourth embodiment ofthe instrument stabilizer of the invention;

FIG. 46 is an exploded perspective view of a fifth embodiment of aninstrument stabilizer of the invention;

FIG. 46a is a longitudinal section view of a sixth embodiment of theinstrument stabilizer of the invention;

FIG. 46b is a longitudinal section of a seventh embodiment of theinstrument stabilizer of the invention;

FIG. 47 is a perspective view of an eighth embodiment of the instrumentstabilizer of the invention;

FIG. 48 is a perspective view of a ninth embodiment of the instrumentstabilizer of the invention;

FIG. 49 is a side view of a stabilizer swivel according to the inventionand in a normal direction;

FIG. 50 is an exploded view of the stabilizer swivel according to theinvention;

FIG. 51 is a side view of the stabilizer swivel in a first angularorientation;

FIG. 52 is a side view of the stabilizer swivel in a second angularorientation;

FIG. 53 is a side view of an instrument stabilizer coupled to thestabilizer swivel in the second angular orientation;

FIG. 54 is a top perspective view of a fifth embodiment of a port deviceaccording to the invention;

FIG. 55 is a longitudinal section view of the fifth embodiment of theport device, shown without the port tube;

FIG. 56 is a transverse section across line 56—56 in FIG. 55 of thefifth embodiment of the port device, shown without the port tube;

FIG. 57 is a perspective view of the fifth embodiment of the portdevice, shown with an introducer inserted therein for movement of theport swivels, the introducer positioned such that the swivels are in anopen position; and

FIG. 58 is a perspective view of the fifth embodiment of the portdevice, shown with an introducer inserted therein for movement of theport swivels, the introducer positioned such that the swivels are in aclosed position.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

According to the invention, a system is provided for performing portoff-pump beating heart coronary artery bypass surgery. The systemincludes a port device and a heart stabilizer.

Turning now to FIG. 1, a first embodiment of the port device 10 includesa tubular body 12, a washer 14 slidably mounted on the tubular body anda locknut 16 threadably coupled to the body 12 proximal of the washer14. The tubular body 12 includes a proximal portion 20 and a distalportion 22. The distal portion 22 includes a clevis 24 defining twocoaxial pivot bores 26, 28, and a pair of clamping swivels 30, 32 arerotatably coupled to the clevis 24 at the pivot bores 26, 28.

Referring to FIGS. 1 and 2 and with reference to swivel 32, each swivelincludes a wing portion 40 with a preferably curved outer surface 42 anda preferably substantially planar inner contact surface 44, and two arms46, 48 each including an axle bore 50, 52. One arm 46 of each swivelincludes an inner recess 54 adapted to permit interleaving of theswivels about the clevis 24. Each arm 46, 48 of the swivel is coupled tothe tubular body 12 with an axle member 56, 58 which extends through arespective axle bore 50, 52 and pivot bore 26, 28, and defines a pivotaxis A_(P). With reference to axle member 56, each axle member includesa relatively cylindrical first portion 60, an elongatetrapezoidal-shaped lever 62, and an interference portion 64 between thefirst portion and lever portion. The interference portion 64 is slightlylarger in diameter than the first portion 62 and includes knurls 66 orother gripping structure. The interference portion 64 of axle member 56engages arm 46 about a respective axle bore, and the first portion 60extends into the clevis bore 26, in which it is freely rotatable, whilethe interference portion 64 of axle member 58 engages arm 48 about arespective axle bore. As such, each axle member 56, 58 is fixedlyattached to only one of the swivels and the swivel pivots about it.Then, as each swivels rotates about the clevis, a respective lever isalso rotated and, similarly, rotation of the individual levers resultsin independent rotation of the swivels. The swivels 30, 32 are rotatablefrom a closed orientation (FIG. 1) in which the swivels extendsubstantially parallel to the body 12 through intermediate orientations(e.g., FIG. 3), and into a open orientation in which the swivels 30, 32extend preferably perpendicular to the first orientation (FIG. 4). Whenin the first orientation, the swivels 30, 32 preferably complete theopenings 72, 74 (FIG. 4) defined by the clevis 24, and the curvature ofthe outer surfaces 42 of the swivels provide the outer surface of thedistal portion 22 with a substantially smooth surface. In addition, inthe first orientation, the levers 62 are preferably oriented transversethe longitudinal axis AL of the body 12.

Referring to FIG. 5, the proximal portion 20 of the tubular body 12includes first and second sets of interrupted helical threads (grooves)72, 74 extending along diametrically opposite sides of the body. Theinterruption 76 in the threads creates stops 78 after substantially 180°of rotation. A longitudinal groove 80 connects each set of threads 72,74 together. The locknut 16, as described hereinafter, travels in thelongitudinal grooves 80 and the threads 72, 74.

Referring now to FIGS. 1, 4 and 5, the proximal end 20 of the body 12includes a coupling structure, e.g., the holes 82 of a ball latch, forremovably coupling thereto the heart stabilizer the hereinafterdescribed port introducer, or other device, as described in detailbelow.

The washer 14 is preferably disc-shaped and has a central opening 84permitting the washer to fit about the tubular body 12 and provides anexternal clamping structure which operates in conjunction with theswivels 30, 32 to clamp human tissue therebetween, as described furtherbelow.

Referring to FIGS. 1 and 6, the locknut 16 includes a central opening86, a handle portion 88, and a ball portion 90. Two nubs 91, 92 radiallyextend into the central opening and are sized to ride within the threads72, 72, 74 and longitudinal grooves 80 on the proximal portion of thetubular body 12 (FIG. 5). As such, when each nub 91, 92 is positionedwithin a respective longitudinal groove 80, the locknut 16 may be movedquickly over the port body 12 and then rotated to thread the nubs 91, 92into the threads 72, 74 to secure the locknut 16 at a desired location10 over the body 12. One preferred manner of forming the nubs 91, 92includes providing two diametrically opposite radial holes 94 in thehandle portion 86 and inserting peg 98 into each radial hole such thatthe pegs extend into the central opening 86 to form the nubs. The ballportion 90 is a truncated sphere in shape and defines a diameterslightly larger than the diameter of the central opening 84 of thewasher 14. Referring to FIGS. 1 and 5, the washer 14 is thereby adaptedto articulate on the ball portion 90 of the locknut 16.

Turning now to FIGS. 7 and 8, an introducer 100 adapted to introduce theport device into an incision in the chest wall and also to effectmovement of the swivels between closed and open configurations is shown.The introducer 100 includes a central tubular handle 102, a proximal cap104, and a mandrel 106 extending through the handle 102 and coupled tothe cap 104. The handle 102 includes a proximal stop notch 107, anddistal smaller diameter portion 108 including two diametrically-opposedhemispherical latch elements 110 for engagement within holes 82 of theport body 12, and which together form a ball latch. The latch elements110 are provided on fingers 112 of the handle 102, which under radialforce are moved radially inward. The cap 104 includes a tubular portion114 provided with a radial hole 116, and a knob 118 which is relativelylarger in diameter than the tubular portion. The tubular portion 114 ofthe cap 104 extends into the handle and the knob 118 seats on theproximal end 119 of the handle. The mandrel 106 includes a cylindricalshaft 120 provided with a radial bore 122 and two diametrically-opposeddistal planar portions 124, and a distal actuator 126. The shaft 120extends through the handle 102 and into the cap 104. A crosspin 128 ispositioned through the radial hole 116 and into radial bore 122 securingthe shaft 120 of the mandrel 106 and the cap 104 together. In addition,the crosspin 128 extends into the stop notch 107 limiting rotation ofthe knob (and mandrel) relative to the handle 102. The planar portions124 provide space to permit radial movement of the latch elements 110when the fingers 112 of the handle 102 are compressed. Referring toFIGS. 7 through 9, the actuator 126 of the mandrel 106 includes apreferably blunt end 130 and a pair of diametrically-opposedsubstantially planar sides 132 about the end 130. A pair ofdiametrically-opposed actuation grooves 134 are provided between theplanar sides 132. The actuation grooves 134 are generally L-shaped andinclude a longitudinal portion 136 which terminates at the blunt end130, and a transverse portion 138. The transverse portion 138 includes anotch 140.

Referring now to FIG. 10, the introducer 100 is coupled to the portdevice 10 by opening the swivels 30, 32 of the port device and insertingthe actuator 126 of the introducer until the ball latch engages; i.e.,the proximal end of the port device rides over the latch elements 110until the latch elements catch in the holes 82 in the port body 12. Withthe swivels 30, 32 in the open configuration, the levers 62 (FIG. 2) arealso aligned within respective longitudinal portions 136 of theactuation grooves 134 and reside therein. More particularly, the pivotaxis A_(P) of the levers 62 are located just proximal of the innercorners 142 of the grooves (FIGS. 2 and 9). Referring to FIGS. 2, 9, 11and 12, while keeping the handle 102 fixed, the knob 118 is rotated in aclockwise direction (causing movement of the grooves 134 relative to thelevers 62. The corners 142 contact the levers 62 and rotate the leversinto the transverse portions of each of the grooves, thereby effectingclosing of the swivels about the port body 12. One end of each leverengages a notch 140 in its respective groove 134 to “lock” the levers(and swivels) in the closed position until the knob is rotated in anopposite direction. The amount of the rotation of the knob 118 relativeto the handle 102 required to effectuate the closing is relativelylimited, e.g., approximately twenty-four degrees with groove 134, andcontact of the crosspin 128 against the top notch 107 limits themovement.

The introducer may be provided with other shaped grooves, the rotationof which effects movement of the levers and swivels. For example,referring to FIG. 31, the J-groove 134a on the introducer 100 a operatesto close (or open) the swivels by clockwise rotation of approximately45°.

The planar sides 132 of the actuator 126 are so shaped such that theswivels 30, 32 may rest thereagainst when the swivels are in the closedconfiguration (FIG. 12) and thereby permit the outer surface of theswivels to effectively complete the circumference of the tubular body ofthe port device.

Once the swivels are locked in a closed configuration about theintroducer 100, the introducer may be manipulated to introduce the portdevice 10 into an incision in a chest wall, preferably between two ribs,or an incision in another area of human tissue. To secure the portwithin the incision, the knob 118 is rotated in a counter-clockwisedirection, releasing the ends of the levers from the notch 140 andcausing the levers to ride against their respective walls oflongitudinal portions 136 and rotate about their pivot axis A_(P). Thisresults in aligning the levers 62 within the longitudinal portions 136of the grooves 134 and moving the swivels into the open configuration(FIG. 10). In the open configuration, it is preferable that the swivelseach be located under a respective rib. The port body 12 is pulled backto contact the ribs and then the washer 14 is moved against the outersurface of the tissue surrounding the incision. The nut 16 is advancedthrough the longitudinal grooves 80 to contact and press against thewasher and then threadably rotated within the threads 72, 74 to lockagainst the washer. The swivels and washer thereby provide a clampingaction about the ribs and tissue and stably secure the tubular body 12of the port device within the chest wall.

The introducer 100 is then released from the port body 12 by depressingthe fingers 112 of the handle 102. Finally, the introducer is withdrawnleaving an open port through which a surgical instrument other devicemay be introduced, and to which a device may be securely coupled. Itwill be appreciated that due to the articulating relationship of theball portion 90 of the lock nut 16 and the washer 14, the tubular port12 may be articulated relative to the washer, and the chest wall.

The port device may be removed from the body by reinserting theintroducer in the port device such that the levers align with and enterthe longitudinal grooves. The introducer is preferably coupled to thetubular body. The locknut is released, and the port device is movedslightly into the chest cavity to provide space for the swivels to fold.Then the knob of the introducer is rotated relative to the handle tocause the actuator to rotate relative to the swivels, and cause theswivels to fold against the tubular body into the closed configuration.The introducer and port device are then together withdrawn from thechest wall of the patient.

Turning now to FIGS. 13 and 14, a second embodiment of a port device 210according to the invention substantially similar to the first embodiment(with like parts having reference numerals incremented by 200) is shown.The tubular body 212 of the port device 210 includes a double helixthread 273 without interruptions. The proximal end of the port deviceincludes a female bayonet coupling 283. The distal end of the tubularbody includes a single swivel 231 including two arms 230, 232 androtatably coupled at a central portion 233 to a clevis 224 formed at thedistal end of the body. The inner contact surfaces 244 of the swivel arepreferably provided with a contour to facilitate placement of theswivels against the ribs even when the tubular body is articulatedthrough various angles relative to the washer. The swivel 231 ispreferably biased with a spring 235 to move into an open configurationsubstantially perpendicular to the tubular body. As such, duringinsertion, a mandrel (not shown) is preferably positioned within thetubular body, and may be coupled to the female bayonet coupling, tomaintain the swivel in a closed configuration substantially parallel tothe tubular body. Then, when the proximal end of the swivel 231 is pastthe ribs (see FIG. 15), the mandrel is removed from the tubular body,and the spring 235 automatically rotates the swivel 231 into the openconfiguration with the swivel being captured by the ribs 350. The washer214 and locknut 216, which are preferably the same as described in thefirst embodiment, are then tightened against the tissue 352 (as shown inFIG. 15), clamping the ribs 350 and tissue 352 between the washer andswivel.

The swivel 231 may be returned to the closed configuration for removalfrom the patient body by loosening the locknut and washer, pushing theswivel distally into the chest cavity, and inserting the mandrel backthrough the tubular body and causing contact against an arm of theswivel to force the swivel to rotate back into the closed configuration.

Turning now to FIG. 32, a third embodiment of a port device 600according to the invention is shown. The port device includes a tubularbody 602 and an adjustable platform 604. The tubular body 602 includesswivels 630, 632 at a distal end thereof, and threads 672, 674 andlongitudinal grooves 680 along the body, preferably the same as thosedescribed with respect the first embodiment. The platform 604 includes acentral opening 606 and nubs which extend into the opening (the nubs arenot shown, but are substantially similar to nubs 91, 92 in the firstembodiment). The nubs permit the platform to travel in the longitudinalgrooves 680 and threads 672, 674 to move and threadably lock theplatform relative to the body 602. The platform 604 also includes aplurality of, e.g., four, threaded bores 700 a-d preferably equallyspaced about the central opening 606. Bolts 702 a-d are thread partiallythrough the bores 700 a-d, and each is provided with a proximal handle704 a-d by which the bolt may be manually rotated, and a distal foot 706a-d pivotable about the end distal end of the bolt.

An introducer 100, shown coupled to the port device 600, is preferablyutilized to insert and deploy the swivels 630, 632 of the port device600 into the chest wall, and is then disengaged and removed from theport. The platform 604 is then angularly adjusted relative to the chestwall by rotating the bolts. That is, if it is desired to have theplatform 604 be oriented substantially planar with the chest wall, eachbolt 702 a-d, by rotation of its respective handle 704 -d, is tightenedby substantially the same amount to cause the chest wall to be evenlyclamped between the swivels 630, 632 and the feet 706 a-d. However, ifit is desired to cause the platform, and port body 602 therein, be at anangle relative to the chest wall (to provide better access to thesurgical site), the bolts 706 a-d may be thread into the bores 700 a-dby different amounts to cause the platform 604 to assume a desired anglerelative to the chest wall.

Referring now to FIGS. 33 and 34, a fourth embodiment of a port device800 according to the invention, substantially similar to the thirdembodiment 600, is shown. The tubular body 802 of the port device isprovided with four sets of grooves 672 a, 672 b (672 c and 672 d notshown but located diametrically opposite 672 a and 672 b, respectively),rather than the threads 672, 674 of body 602 (FIG. 32). Each set ofgrooves 672 a-d extends parallel to a respective tangent on the surfaceof the body and offset by ninety degrees about the body. The platform804 includes four radial channels 810 a, 810 b (810 c and 810 d notshown) located ninety degrees apart. A ratchet pin 812 is provided ineach of the channels 810 a-d. A spring 814 is positioned within eachchannel 810 a-d to bias each ratchet pin 812 toward a respective set ofgrooves 672 a-d, and a locking collar 816 maintains the spring withinthe channel. The ratchet pin 812 is shaped to include a beveled edge 818facilitating radial outward movement of the ratchet pin against the biasof the spring when the platform is moved distally over the grooves ofthe tubular body. In addition, the ratchet pin includes a stop 820 tolimit inward radial movement. This configuration permits the platform tobe readily and rapidly moved distally along the tubular body to adesired location with the ratchet pins locking within the grooves toprevent proximal movement of the platform, and thereby clamping thechest wall between the swivels 830, 832 and the feet 806 a-d coupled tothe platform. The feet may then be adjusted to orient the platform at anangle relative to the chest wall.

When it is desired to release the platform from about the tubular body,the feet are loosened from against the chest, and the platform isrotated approximately forty-five degrees such that the ratchet pins liealong smooth portions 822 of the tubular body. The platform may then bemoved proximally relative to the tubular body without substantialresistance.

Turning now to FIGS. 54 through 58, a fifth embodiment of a port device1800 according to the invention is shown. The port device 1800 includesa port tube (tubular body or port body) 1802 (FIGS. 57 and 58), aplatform 1804 (FIG. 54), and a plurality of legs 1806 (FIG. 54).Referring to FIGS. 57 and 58, the port tube 1802, at a distal end,includes a pair of swivels 1830, 1832 coupled to the tube with axlemembers, as described above (see FIG. 2), and a proximal body 1812having a plurality of longitudinally-spaced circumferential grooves1872. The proximal end of the body includes preferably two diametricallyopposite catches 1882 for receiving latches of an introducer, andcoupling thereto, as described below.

Referring back to FIGS. 54 through 56, the platform 1804 is preferablygenerally triangular-shaped and includes a central opening 1900 (FIG.56) in which to receive the port tube 1802, and three peripheral legholes 1902 preferably located adjacent the corners of the platform inwhich to receive the legs 1806. Three ratchet pins 1904, each having abeveled lower edge 1905, are evenly spaced about the central opening1900. The ratchet pins 1904 are biased by respective springs 1906 toextend radially inward into the central opening 1900. Each ratchet pin1904 includes an upwardly extending convex boss portion 1908. A porttube release collar 1910 is provided within the central opening 1900 andincludes a central passageway 1911. The ratchet pins 1904 extend intothe central passageway 1911. The collar 1910 also includes a convexgroove 1912 over each boss portion 1908. In addition, the collarincludes a slot 1914 between each groove 1912. One peg 1916 extendsthrough each slot 1914, and is fixed in the platform, permitting thecollar 1910 to be rotated relative to the central opening 1900 a limitedamount; i.e., the distance the peg 1916 may travel within the slot 1914.Moreover, the pegs 1916 couple the collar to the platform 1804 andprevent its release. When the collar 1910 is rotated relative to theplatform 1804 from a first position in which the center of each groove1912 is positioned over a respective boss portion 1908, the respectivesurfaces of the convex grooves contact the boss portions and move theratchet pins 1904 against the bias of the springs 1906 to retract theratchet pins from the central opening 1900. The collar 1910 preferablyincludes upper knob portions 1917 grippable by human fingers tofacilitate the limited rotation of the collar 1910 relative to theplatform and the resulting ‘release’ of the ratchet pins.

When the platform 1804 is distally forced over the port tube 1802, thegrooves 1872 of the port tube 1802 contact the beveled ratchet pins 1904and cause radial outward movement of the pins against the bias of thesprings 1906. When the platform 1804 is moved a desired distance overthe port tube 1802, the relative distal force is removed and the ratchetpins engage within the grooves to prevent proximal movement of theplatform relative to the tube. The platform 1804 may then be releasedfrom over the port tube 1802 by rotation of the collar 1910 relative tothe platform. This configuration permits the platform to be readily andrapidly moved distally along the port tube to a desired location withthe ratchet pins locking within the grooves of the port tube to preventproximal movement of the platform.

Each of the legs 1806 includes a generally cylindrical shaft 1920, anupper knob 1922 facilitating downward (distal) force to be placed on theleg, and a lower foot 1924 which is pivotable on the distal end of theshaft 1920. A portion along a length of the shaft 1920 includes a rackof teeth 1926 defined by grooves 1928 cut parallel to a tangent of theshaft. Each shaft 1920 is provided into a respective leg hole 1902 ofthe platform 1804. The platform includes, for each leg hole, a ratchetpin 1930 having a convex tip 1932 with a beveled upper surface 1934. Theratchet pin 1930 is biased by a spring 1936 to extend radially into theleg hole 1902. Each leg may be easily and rapidly moved distallyrelative to the platform 1804 by pushing the leg distally, causing thebeveled upper surface 1934 to contact the teeth 1926 and be movedradially inward against the bias of the spring 1936 to permit movementof the leg 1920 through its respective leg hole 1902. However, the legsare prevented from relative proximal movement by the capture of theratchet pin 1932 in a groove 1928 between the teeth 1926. Each leg maythen be released by rotating the leg relative to the platform such thatthe inner surface of the groove 1928 in which the ratchet pin 1930 seatscontacts the tip 1932 of the pin and moves the pin out of the leg hole.When the leg is sufficiently rotated to cause a cylindrical portion ofthe leg to be facing the ratchet pin 1934, the pin is prevented fromentering the leg hole and cannot contact the teeth or enter the grooves,as the teeth and grooves are rotated out of the way. As such, the legsmay then be freely moved proximally and distally. It will be appreciatedthat the legs may be independently moved relative to the platform topermit a variety of longitudinal and angular adjustments. In addition,the legs define a tripod which is extremely stable. Furthermore, thedegree of adjustment and clamping ability is also facilitated by theadjustability of the platform relative to the tube.

Referring now to FIGS. 57 and 58, an introducer 2000 is coupled to theport device to aid insertion of the port device into the chest wall andto enable movement of the swivels into the clamping positions. Theintroducer includes a mandrel 2002 extending through a guiding sleeve2004. The mandrel 2002 includes a handle 2006 at a proximal end, acentral shaft portion 2008, and a distal actuator 2010. A pin 2012 isprovided in a proximal portion of the shaft and protrudes above thesurface of the shaft. The actuator 2010 includes a J-hook groove, asshown with respect to the J-hook groove 134 a of the actuator 100 a(FIG. 31). The sleeve 2004 includes a proximal J-hook slot 2016 anddistal resilient fingers 2018 having tabs or latches 2020 adapted toengage the catches 1882 of the port tube 1802.

In operation, the swivels 1830 and 1832 of the port 1800 are firstmanually moved into an open configuration. Next, the sleeve 2004 of theintroducer 2000 is coupled to the port 1800 by engaging the tabs 2020 ofsleeve 2004 in the catches 1882 of the port tube 1802. The mandrel 2002is then inserted through the sleeve 2004 such that the pin 2012 on themandrel is aligned with the proximal end of the J slot 2016 of thesleeve. This causes the levers 62 (FIG. 2) of the open configurationswivels to be aligned with the distal end of the J-groove of theactuator 2010. Referring to FIG. 58, the handle 2006 is then moveddistally and rotated relative to the sleeve 2004 to move the pin 2012through the slot 2016 in the sleeve to the distal end of the slot.Consequently, the actuator is moved in a manner which causes theJ-groove to guide the levers in a manner which rotates the swivels 1830,1832 into a closed configuration.

The introducer 2000 is then maneuvered to insert the closed port tube1802 through an opening in the chest wall. The handle is then operatedin an opposite direction to open the swivels 1830, 1832 in the chestwall. The platform 1804 is then moved over the introducer 2000 andratcheted over the port tube to clamp the chest wall between the openswivels and the feet 1924 of the legs 1920. The legs 1920 may then beratcheted distally or released to be moved proximally relative to theplatform to desirably orient the port tube relative to the chest wall.The introducer is then released by radially inwardly compressing theresilient fingers 2018 to release the tabs 2020 from the catches 1882and then withdrawing the introducer 2000 from the port tube 1802.Endoscopic instruments may then be inserted through the port tube 1802,as discussed above.

When the procedure is complete, the introducer is again coupled to theport tube, and the platform may be released from over the port tube byreleasing the ratchet engagement from the legs and port tube. Theintroducer is then operated to move the swivels into the closed positionand the port tube is withdrawn from the chest wall.

While the port device has been disclosed with various swivel elements,it will be appreciated that other swivel elements, and means for openingthe swivel elements, including springs and mechanical systems may beused as well. In addition, while particular types of connecting meansfor coupling devices, e.g., the introducer and surgical instruments tothe port have been disclosed, it will be understood that otherconnecting means can be used. Also, while various means for orientingthe port device relative to the heart wall have been disclosed, it willbe appreciated that other such orienting means can be used was well.Furthermore, it will be appreciated that any one or more of the featuresof the individual port device embodiments may be incorporated into theother embodiments.

Turning now to FIG. 16, a first embodiment of the heart stabilizer 400preferably includes a hollow shaft 402, a rod 404 extending through theshaft, and a proximal control handle 406 coupled to the proximal ends ofthe shaft 402 and rod 404 to move the rod longitudinally within theshaft, as described in more detail below. The shaft 402 and rod 404 arekeyed (not shown) such that the rod cannot rotate relative to the shaft.A shaft lock 407 is provided about the shaft 402 and operates to lockthe heart stabilizer 400 to a port device, such as port devices 10(FIG. 1) and 210 (FIG. 13), and also permits locking the shaft 402 innumerous longitudinal and angular positions relative to the port device.

More particularly, referring to FIGS. 16 and 17, the shaft lock 407includes a port connector 408 a, a cap 408 b, and a ball element 409between the port connector and cap. The ball element 409 includes ashaft bore 410, a first set of diametric slots 411 a in one end of theball element, and a second set of diametric slots 411 b in the other endof the ball element. The two sets of slots 411 a and 411 b permit radialcompression of the ball element 409 to cause the diameter of the shaftbore 410 to decrease. The port connector 408 a and cap 408 b eachinclude an opening 412 a, 412 b, a mating means 413 a, 413 b, e.g.,threads, for mating with each other, and a finger gripping structure 414a, 414 b to facilitate relative rotation of the port connector and capabout the mating means. The port connector 408 a also includes a portmating structure 415, e.g., a bayonet, for mating with the femalebayonet coupling 283 of a port 210 (FIG. 14). The shaft 402 extendsthrough the shaft bore 410 and, when the port connector 408 a, 408 b areloosely mated with each other, the shaft and ball element 409 may bepivoted relative to the port connector and cap, and the shaft may bemoved longitudinally within the bore 410 relative to the shaft lock.When the cap 408 b is tightened on the port connector 408 a, the ballelement 409 and shaft 402 are locked in their respective positions.

Referring to back to FIG. 16, the control handle 406 includes a knobmount 416 fixedly coupled to the proximal end 402 a of the shaft 402,and a knob 417 rotatably coupled to the mount 416. The knob 416 includesa threaded bore 417, and the proximal end 404 a of the rod 404 isthreaded, and threadably engaged within the bore of the knob 417. Therotation of the knob 417 relative to the mount 416 causes the rod 404 tomove longitudinally relative to the shaft 402, as the keyed rod cannotrotate relative to the shaft.

Referring now to FIGS. 16, 18 and 19, the distal end 402 b of the shaft402 is provided with a collar 418. The distal end 404 b of the rod 404is coupled to a clevis 422. The clevis 422 includes a post portion 432coupled to the rod 404, a frustoconical portion 434, and a U-shapedsocket 436 including side walls 438, 440 with spherical concavities 442,a back wall 446, and a front opening 448 extending through anapproximately 180° arc. A slot 450 extends from the back wall 446,through the frustoconical portion 434, and into the post portion 432.When the rod 404 is moved proximally relative to the shaft 402, byoperation of the handle 406, the collar 418 rides against thefrustoconical portion 434 of the clevis 422, causing compression of thesocket 436. Conversely, when the rod 404 is moved distally relative tothe shaft 402, the frustoconical portion 434 of the clevis 422 isreleased from the collar, permitting the socket 436 to slightly expand.

Referring to FIGS. 18 through 21, two articulating arms 424, 426 arecoupled in the socket 436 of the clevis, and a rotatable stabilizingfoot 428, 430 is coupled to the end of each arm. The first and secondarticulating arms 424, 426 each include an upper arm 450, 452, a lowerarm 454, 456, and a wrist mount 458, 460. Stabilizing feet 428, 430 arecoupled to the wrist mounts, 458, 460, respectively. The articulatingarms 424, 426 and the feet together define a stabilizing assembly 461.

More particularly, each of the first and second upper arms 450, 452includes a partly hollow, generally hemispherical shoulder 462, 464 atone end and an upper elbow portion 466, 468 at the other end. The firstshoulder 462 (of the first upper arm) includes rim 470 defining a firstupper cam 472, and the second shoulder 464 (of the second upper arm)includes a rim 476 defining a second upper cam 478. In addition, each ofthe first and second upper arms includes a pin bore 480, 482 extendinglongitudinally through the arms. Lock pins 484, 486, which function tolimit the movement of the first and second upper arms 450, 452 relativeto each other as described in more detail below, are provided within thepin bores 480, 482.

The first and second shoulders 462, 464 are oriented and configured suchthat they together substantially define a sphere. A shoulder spring 487is positioned within the sphere defined by the shoulders, and the ends488, 490 of the spring 487 are coupled to and about the rims 470, 476,respectively, with the spring 487 under helical compression to urge theupper arms 450, 452 away from each another. A spacer 492 is providedwithin the spring 487 to stabilize the spring within the shoulders. Theshoulders together are provided in the socket 436, with eachhemispherical shoulder residing partially within a respective one of theconcavities 442. While the shoulders 462, 464 appear to form a ballwithin the socket 436, it will be appreciated that the shoulders provideadditional function over a ball in that the two upper arms 450, 452 arepermitted to independently rotate relative to each other at theshoulders. The spring 487 is adapted to bias the upper arms 450, 452into an open position in which the two are in alignment; i.e., atsubstantially 1800 relative to each other. Each upper arm 450, 452 alsoincludes a front bevel 494, 496. As such, when the upper arms are movedagainst the bias of the spring 487 toward each other, an angle α assmall as approximately 45°, and preferably 47°, may be definedtherebetween (FIG. 20), with the bevels 494, 496 minimizing interferencebetween the two upper arms which would otherwise limit the ability todefine such a small angle α therebetween.

The description of the lower arms 454, 456 and the coupling of the lowerarms to the upper arms will now be described with respect to upper arm450 and lower arm 454 of the first articulating arm 424, with it beingunderstood that the lower arms and their couplings of the secondarticulating arm 426 are each substantially the same as in the firstarticulating arm, but installed upside down relative to the firstarticulating arm.

The upper elbow portion 466 of upper arm 450 is rotatably coupled to alower elbow portion of lower arm 454. The upper elbow portion 466 isgenerally hemispherical in shape and includes a countersunk screw hole500 and a first elbow spring catch 502. The upper arm 454 is providedwith a bevel 504 adjacent the upper elbow portion 466. The lower arm 454includes a generally hollow, substantially hemispherical lower elbowportion 510 which mates with the upper elbow portion 466 of the upperarm 450. The lower elbow portion 510 includes a rim 512 defining asecond elbow spring catch 514, and a lower arm cam 516 including a camlock 518 and a cam stop 520. The elbow portion 510 also includes athreaded screw hole 522.

An elbow spring 524, under helical tension, is provided within the upperand lower elbow portions 466, 510. The elbow spring 524 includes ends526, 528 which are coupled in the first and second elbow spring catches502, 512, respectively, biasing the upper and lower arms toward aconfiguration having a relatively smaller angle therebetween. A tubularspacer 530 is provided within the elbow spring 524 to stabilize thespring within the shoulders and provide a pathway for a screw 532 whichextends into the screw hole 500 and is threadably engaged in screw hole522 to secure the upper and lower arms together in a manner whichpermits the lower arm to pivot relative to the upper arm.

The lower end of the lower arm includes an upper wrist portion 540provided with a rim 542 oriented orthogonally to the rim 512, and athreaded bore 548. The rim 542 defines a first wrist spring catch 544and a stop 546.

The wrist mount 458 includes a second wrist spring catch 550, athroughbore 552, and two threaded mounting holes 554, 556; one providedon either side of the throughbore 552. A wrist spring 558 is providedabout a spacer 560 between the upper wrist portion and the wrist mountand engages the first and second wrist spring catches. The wrist spring558 is biased to rotate the wrist mount 458 clockwise relative to theupper wrist portion 540 when viewed in the direction of the lower arm454 toward the wrist mount 458. A wrist spring 558′ in the second arm426 rotates a respective wrist mount in an opposite direction such thatthe wrist mounts are urged to rotate away from each other.

A collar 562 is provided in alignment with the throughbore 552, and ascrew 564 extends through the collar 562 and throughbore 552 and issecured in the threaded bore 548 of the upper wrist portion 540.

The foot 428 includes an outer surface 566, a contact surface 568, andtwo spaced apart bores 576, 578 which align with the threaded bores 554,556 of the wrist mount 458. The foot 428 is coupled at its outer surface566 to the wrist mount 458 with screws 580, 582 extending into the bores576, 578 and threadably engaged within bores 554, 556 of the wrist mount458.

The operation of the heart stabilizer 410 and particularly thestabilizing assembly 461 will now be described, with reference numeralsterminating in a prime referring to elements of the second articulatingarm. Referring to FIGS. 20 and 21, the articulating arms 424, 426 andfeet 428, 430 are manually folded into the illustrated configuration.That is, the upper arms 450, 452 are folded about the shoulders, and thefeet 428, 430 are rotated inward toward each other such that therespective contact surfaces 568, 568′ and in contact. In thisconfiguration the upper arms 450, 452 have an angle α of approximately47°, and the feet 428, 430 are oriented substantially parallel to theshaft 402 of the heart stabilization device 410. The handle 406 is thenoperated to cause the collar 418 to compress the socket 436 about theshoulders 462, 464 of the upper arms and thereby lock the upper arms450, 452, lower arms 454, 456, and feet 428, 430 in their relativepositions and present a relatively small cross-sectional area forinsertion through a port 210.

The stabilizing assembly 461 is inserted into a port 210 (FIG. 22) whichis mounted in a chest wall of a patient's body (not shown). The shaftlock 407, loosely provided about the shaft 402, is slid along the shaft402 toward the port, and the port connector 408 a of the shaft lock isthen coupled to the port (FIG. 23). The shaft 402 is then moved throughthe shaft lock 407 until the stabilizing assembly 461 is moved beyondthe swivel 231 of the port 210 to a location within the chest cavitypermitting expansion of the stabilizing assembly 461 (FIG. 24). Theshaft lock 407 is then tightened to retain the shaft 402 at the selectedlocation relative to the port 210.

The knob 407 of the handle 406 is then operated to release the socket422 from compression by the collar 418, thereby permitting movement ofthe articulating arms 424, 426 in accord with the forces of the springsand lock pins in the arms. More particularly, referring to FIGS. 20 and25 through 27, when the socket is released, shoulder spring 487 operatesto move the upper arms 450, 452 from a closed position (α equalsapproximately 47° in FIG. 20) toward a more open position (α equalsapproximately 87° in FIG. 25, and α equals approximately 126° in FIG. 26and 27). In addition, elbow springs 524, 524′ operate to bend the lowerarms 454, 456 relative to the upper arms 450, 452 toward a smallerrelative angle β. In FIG. 20, β is approximately 156°; in FIG. 25, β isapproximately 135°; and in FIG. 26, β is approximately 111°. Referringto FIG. 28, when α is approximately 163°, β is substantially 90°, andthe distal ends 586, 586′ of the lock pins 484, 484′ in the upper arms450, 452 engage the cam locks 518, 518′ of the elbows 510, 510′ of thelower arms 454, 456. Then, as shown in FIG. 29, when the angle α issubstantially 180°, the lock pins 484, 484′ are engaged by the cams 472,478 on the upper arms to lock the upper and lower arms at an angle β of90°. It is noted that β is dependent on a only in that as α increases,so does β as a result of the springs in the elbow joints. The only fixedrelationship between α and β are when the arms are fully folded, orfully deployed. It will be appreciated that this above describeddeployment and arm locking is automatic after the socket 436 is releasedfrom the collar 418. After deployment, the handle 406 may be operated tocause the collar to again clamp on the socket to prevent any relativemovement of the upper arms which may otherwise potentially destabilizethe stabilizer assembly 461.

Once the upper and lower arms are locked relative to each other, theshaft 402 (FIG. 16) may be unlocked from the shaft lock 407 andlongitudinally moved such that the contact surfaces 568, 568′ of thefeet 428, 430 contact the heart wall. The feet are adapted to rotate atthe wrist mounts 458, 460 relative to the lower arms to contour to theheart wall. The stops 546 on the lower arms (FIG. 19) preferably limitrotation of the feet to ninety degrees relative to the orientation shownin FIG. 21. The shaft 402 is again locked within the shaft lock suchthat the feet apply sufficient pressure against the wall of the heart toeffectively immobilize motion of the heart wall between the feet suchthat the bypass procedure may be performed between the feet.

Furthermore, after the port off-pump coronary artery bypass procedure,when it is desired to withdraw the heart stabilizer through the port,the handle 406 may be operated to unlock the stabilizer assembly 461.The shaft of the stabilizer is then released from the shaft lock and/orthe port connector of the shaft lock is released from the port, and thenthe stabilizer assembly is forced proximally. When the upper armscontact the port, the upper arms are forced to fold in a reverseoperation to deployment, i.e., to a smaller angle α and release the lockpins from the cams and cam locks. As the upper arms fold about theshoulder, the contact surfaces of the feet contact each other and rotatesuch that the contact surfaces are substantially coplanar. This, inturn, causes the lower arms to rotate about the elbow such that anincreased angle β is provided between the upper and lower armspermitting withdrawal of the assembly through the port.

According to various embodiments of the heart stabilizers the feet ofthe stabilizer may be further adapted to facilitate immobilization ofthe heart wall between the feet. In addition to compressive forces, thefeet may be adapted to apply suction, chemical agents, electricalcurrent, or thermal cooling to enhance the heart wall immobilization.

In addition, while various means for opening, and limiting the extent ofopening, of the stabilizing assemblies of the heart stabilizer have beendisclosed, it will be appreciated that other means providing the samefunction may be used. Moreover, while particular preferred anglesbetween the elements of the stabilizing assemblies have been disclosed,it will be appreciated that other preferred angles can be used, withangles other than those disclosed causing engagement of the cams to lockthe arms.

Referring now to FIGS. 35 through 37, a first embodiment of aninstrument stabilizer 1100 is shown. The instrument stabilizer 1100includes a cannula 1102 through which an endoscopic instrument, e.g, alaparoscopic instrument, can extend. Endoscopic instruments, in general,are instruments which are extendable through a scope, or operated inconjunction with a scope, used to view the inside of a body cavity. Thedistal end 1106 of the cannula 1102 is provided with a tapered ferrule1108 including an O-ring 1110 adapted in size to contact an endoscopicinstrument extending therethrough. The proximal end 1112 of the cannula1102 is coupled to a proximal housing 1114 of the instrument stabilizer.

The proximal housing 1114 includes an upper shell 1116 and a lower shell1118, and a disc 1120 stabilized therebetween. The upper shell 1116includes a central opening 1122 through which an endoscopic instrumentmay extend. The lower shell includes a relatively larger central opening1124, and optionally includes a mating structure, e.g., a nub 1126,adapted to couple the housing 1114 to a mating structure on one of theabove described ports, or another port. The disc 1120 is preferablystabilized with preferably three equally-spaced springs 1128 provided oneither side of the disc. To maintain the springs 1128 in their relativepositions, each side of the disc and the corresponding interior surfacesof the upper and lower shells include recesses 1130 into which the endsof the springs are provided. The upper and lower shells 1116, 1118 arethen coupled together about the disc 1120, e.g., via sonic welding, athreaded coupling, or a plurality of fasteners such as screws. The disc1120 includes a central opening 1132 in which the proximal end 1112 ofthe cannula 1102 is fixed, e.g., by interference fit or gluing.Alternatively, the cannula 1102 may be snugly fit within the centralopening 1132 and permitted to move longitudinally therein to adjust theextension of the distal end 1106 of the cannula relative to the housing1114.

Turning now to FIGS. 38 and 39, the instrument stabilizer 1100 may beinserted through a port, e.g., port 210, provided in the body of apatient. The distal end 1106 of the cannula 1102 is extended through theport and the mating structure 1126 (FIG. 35) may then be coupled to themating structure 283 on the port thereby rigidly fixing the instrumentstabilizer and the port together (FIG. 39). An endoscopic instrument1138 may then be inserted through the opening in the upper shell andthrough the cannula. As the endoscopic instrument 1138 exits the distalend of the cannula 1102, the instrument contacts the O-ring 1110 therebycreating an interference between-the instrument and the O-ring such thata slight resistance to movement of the endoscopic instrument isprovided. The spring-stabilized disc 1120, in conjunction with the bodytissue, operates to stabilize lateral movement of the endoscopicinstrument 1138, while the O-ring 1110 operates to stabilizelongitudinal movement of the instrument 1138. As a result, slightforces, e.g., hand tremors, to which the endoscopic instrument issubject are damped. Moreover, as the contact between the O-ring and theinstrument is preferably located at the distal end of the cannula, aneffective fulcrum for the instrument is provided relatively close to thesurgical site, facilitating direction of the instrument and reducingmuscle fatigue.

Referring now to FIGS. 40 and 41, a second embodiment of an instrumentstabilizer 1200 according to the invention is shown. The instrumentstabilizer 1200 includes a cannula 1202 and a housing 1214 having astabilized disc 1220, as described with respect to the first embodiment.The cannula 1202 is preferably interference fit within an opening in thedisc 1220 such that the cannula may be slid relative thereto, yetmaintains its relative position unless subject to a sufficient relativelongitudinal force. The proximal end 1212 of the cannula is providedwith a ferrule 1240. In addition, the distal end 1206 of the cannula,rather than being provided with a ferrule and grommet (as in the firstembodiment), is provided with a taper. The distal end 1206 may betapered by providing one or more slits 1242 in the distal end andcompressing the end about the slit or slits. The taper is sufficient toresult in close contact between the cannula and an instrument extendingthrough the cannula.

Referring to FIG. 40, in accord with one preferred aspect of the secondembodiment, a trocar 1250 may be positioned within the stabilizer 1200such that a sharp, boring tip 1252 of the trocar extends out the distalend of the cannula. Then, when it is desired to use the instrumentstabilizer, the trocar tip and stabilizer are punctured through thetissue of the patient, and the trocar is then removed leaving thestabilizer in place. This permits quick and easy insertion of thestabilizer, creates only a relatively small entry hole, and does notnecessitate the use of a port. As an alternative to a sharp tippedtrocar, the trocar may include a blunt cautery tip, which permitscautery current to be applied to cut through the chest wall, but issufficiently blunt to be relatively atraumatic when cautery current isnot applied.

Referring to FIGS. 40 and 41, in accord with another preferred aspect ofthe second embodiment, a flange 1244 is provided about the circumferenceof the housing 1214. The flange includes a plurality of preferablyevenly spaced-apart suture holes 1246. The suture holes 1246 providelocations at which the instrument stabilizer may be sutured directly tothe patient. Other means for coupling the instrument stabilizer directlyto the patient may also be used. For example, the lower surface 1219 ofthe lower shell 1218 is preferably convex and may be provided with anadhesive capable of temporarily adhering the instrument stabilizer tothe skin of the patient. As yet another example, the lower shell 1218may be adapted to apply a vacuum against the skin of the patient.Portions of the lower shell 1218 may be selectively coupled to the skinthrough the use of several suction zones (e.g., four, each extendingthrough a quadrant of the lower shell) which can be individuallyselected to apply suction. As such, the stabilized disc is then clearlyable to operate in conjunction with the damping properties of the fleshof the patient to dampen errant movement applied to an endoscopicinstrument extending through the stabilizer 1200.

Turning now to FIG. 42, a third embodiment of an instrument stabilizer1300, substantially similar to the first embodiment, is shown. The thirdembodiment includes a single set of springs 1328 located between thelower shell 1318 and the lower side of the disc 1320. The upper shell1316 includes a concave, preferably hemispherical interior surface 1346.The upper side of the disc 1320 is provided with a hemispherical portion1348. A central opening 1332 extends through the disc 1320 including thehemispherical portion 1348 of the disc. The hemispherical portion 1348is forced by the springs against the concave interior surface 1346 ofthe upper shell. The cannula 1302 is provided with a distal bushing 1310having an opening (not shown) sized to be in close contact with aninstrument extending through the cannula. As the instrument is movedrelative to the housing 1314, the hemispherical portion 1348 of the disc1320 articulates relative to the interior surface 1346 of the uppershell 1316. However, movement of the instrument is damped by the springs1328.

Referring now to FIGS. 43 through 45, a fourth embodiment of aninstrument stabilizer 1400, substantially similar to the firstembodiment, is shown. The instrument stabilizer 1400 includes upper andlower shells 1416, 1418, and a disc 1420 therebetween. The disc 1420 isprovided between the upper and lower shells, and includes six radialslots 1450 and a radial bore 1452 centrally located relative to eachslot. Each radial bore 1452 is provided with a first end 1454 of a strut1456. The interior of each shell 1416, 1418 includes sixcircumferentially positioned, equally spaced apart strut mounts 1458.The strut mounts 1458 are provided with alternating upper and lowerstrut purchases 1460, 1462, angled downward and upward, respectively(FIG. 43), on which to receive a second end 1464 of a respective strut1456. The upper shell 1416 includes a circular channel 1466, and thelower shell 1418 includes a circular ridge 1468 sized to fit within thechannel 1466. The upper and lower shells 1416, 1418 are sandwiched aboutthe disc 1420 such that second end 1464 of the struts 1456 are receivedby the respective strut mounts 1458 of the upper and lower shells, andsuch that the ridge 1468 fits within the channel 1466. The shells 1416,1418 are then assembled together and sealed to each other, e.g., viasonic welding. With the shells assembled, alternating struts 1456 arebent in upward and downward configurations. Together the struts providea stabilizing force to the disc. The cannula 1402 is coupled within thedisc 1420, and movement of an endoscopic instrument through an O-ring1410 in a ferrule 1408 of the cannula 1402, is thereby damped.

Referring now to FIG. 46, a fifth embodiment of an instrument stabilizer1500 is provided. The instrument stabilizer 1500 includes a cannula 1502coupled to a housing 1514. The cannula 1502 is provided with a proximalhemispherical head 1509 providing an opening into the cannula, and adistal grommet 1510 sized to be in close contact with an endoscopicinstrument extending through the cannula. The housing 1514 includes alower platform 1518, an upper cap 1516, and a central ring 1519therebetween. The upper cap 1516 includes a concave interior surface(not shown) on which the hemispherical head 1509 can articulate, and aninterior lip (not shown). The lower platform 1518 includes a centralopening 1570, a peripheral circular ridge 1572 provided with a pluralityof spaced apart slots 1574, and an outer-lip 1575. A collar 1576 isrigidly coupled about a portion of the cannula 1502, and positionedwithin the ridge 1572 of the platform 1518. The collar 1576 includes aplurality of slots 1578 corresponding to the slots 1574 on the ridge1572. One or more elastic or resilient band or bands 1580 extend betweenand within the slots 1574 and 1578 to stabilize the collar 1576 relativeto the opening 1570 of the platform 1518. The central ring 1519 includesan outer wall 1582 and a plate portion 1584 with a central opening 1586.When the upper cap 1516 is joined with the platform 1518, the outer wall1582 is held between the interior lip of the upper cap 1516 and theouter lip 1575 of the platform 1518. The plate portion 1584 operates toprevent disengagement of the bands 1580 from the slots 1574, 1578 whenthe housing 1514 is assembled and the cannula 1502 is moved relative tothe housing. When an instrument is positioned through the cannula 1502and in contact with the grommet 1510, movement of the instrument isdamped and stabilized by the close fit arrangement of the grommet 1510and the forces of the bands 1580 on the collar 1576 and cannula 1502.

Referring now to FIG. 46a, a sixth embodiment of an instrumentstabilizer 1500 a is shown. The instrument stabilizer 1500 a includes acannula 1502 a interference fit in a disc 1520 a, as described in thesecond embodiment. The proximal end 1512 a of the cannula 1502 a isprovided with a ferrule 1540 a, and the distal end 1506 a is providedwith a ferrule and-grommet, as in the first embodiment. Upper and lowershells 1516 a, 1518 a. in a threaded engagement surround the disc 1520a. A plate 1560 a is provided against the interior upper surface of theupper shell and permitted to rotate relative thereagainst. Compressionsprings 1528 a. are provided on each side of the disc, as described withrespect to the first embodiment, such that the disc 1520 a ‘floats’between the upper and lower shells. The shells 1516 a and 1518 a may berotated relative to each other such that the shells the springs arefurther compressed (e.g., via clockwise rotation) and reduced incompression (e.g., via counterclockwise rotation), thereby controllablyaltering the stabilizing force upon the cannula. Other mechanisms toalter the amount of force on the cannula can also be used.

Furthermore, in any of the above embodiments of an instrumentstabilizer, the bushing may be adjusted to affect the amount of frictionapplied to the instrument extending therethrough. For example, as shownin FIG. 46b, a bushing assembly 1550 b may be provided at the proximalend of the instrument stabilizer 1500 b. Positioning the bushingassembly 1550 b at the proximal end of the stabilizer 1500 b permitsmanipulation of the bushing assembly while the stabilizer is insertedinto a human body. The bushing assembly 1550 b includes a body 1552 bwhich is rigidly coupled to the cannula 1502 b, a cap 1554 b which isthread onto the body 1552 b, and an elastomeric bushing 1556 b in acavity 1558 b of the body. The bushing 1556 b seats snugly within thecavity 1558 b. Threadably tightening the cap 1554 b on the body 1552 babout the bushing causes a center portion 1560 b of the cap to compressthe bushing. This results in the diameter of the open center 1562 b ofthe bushing 1556 b decreasing and tightening about an instrumentextending through the cannula.

In addition, still referring to FIG. 46b, in any of the aboveembodiments, the pathway 1568 b for the endoscopic instrument mayoptionally be provided with a valve 1570 b to permit the instrumentstabilizer to be used for surgical procedures requiring insufflation ofthe body cavity in which the instrument stabilizer is inserted. Thevalve 1570 b may be provided within the cannula 1502 b or at a locationproximal or distal of the cannula. In FIG. 46b, the valve is locatedwithin the bushing assembly 1550 b. When the valve 1570 b is in a closedposition, fluid is substantially prevented from passing through thecannula. Preferably, insertion of an endoscopic instrument through intothe cannula and against the valve automatically opens the valve suchthat the endoscopic instrument may be moved through the cannula.

Turning now to FIG. 47, an eighth embodiment of an instrument stabilizer1600 is shown. The instrument stabilizer 1600 includes an instrumentcoupler 1602 and a preferably stable shaft 1604. The instrument coupler1602 is preferably elastic and preferably includes a central collar 1603and plurality of rings 1606 or other instrument gripping means, e.g.,ties, collars, tubes, clamps, etc., coupled via an elastic tether 1608to the preferably ring-shaped shaft collar 1603. The shaft 1604 may bededicated to the instrument stabilizer, or optionally may be astabilized shaft of another instrument, e.g., the above described heartstabilizer or another instrument which is substantially stable during asurgical procedure. A surgical instrument 1630 is inserted through oneof the rings 1606. Several rings may be occupied by several surgicalinstruments; the rings being preferably selected based on those whichprovide best access to the surgical site. The elastic tethers extendingfrom the rings to the shaft collar operate to dampen the unwantedmovements to which the surgical instruments are subject. In addition,referring to FIG. 48, instrument coupler 1602 may be used on a pluralityof shafts 1604 such that a single instrument 1630 is stabilized by morethan one coupler 1602, further damping forces to which the instrument1630 is subject.

It is intended that the various features of the several embodiments maybe utilized in other combinations. Also, while various means forcoupling an instrument stabilizer to a patient's body or a port or ashaft (in the case of the sixth embodiment), have been disclosed, itwill be appreciated that other suitable means may be used. Furthermore,while in the first through seventh embodiments of the instrumentstabilizer, the cannula is coupled to a disc which is stabilized withinthe housing, plates other than disc-shaped, e.g, triangular, may beused. Moreover, other damping means may be used. For example, a rubberor other resilient-material plate held within the housing can be used.Such a rubber plate is self-damping and does not require any springs,bands, etc. In addition, while various means having been disclosed forstabilizing and damping the forces to which a surgical instrument and acannula are subject, it will be appreciated that other means maylikewise be used. Furthermore, while an O-ring, a grommet, and a taperedcannula have been disclosed for providing a close fit arrangement with acannula, other close fitting bushings, e.g., a diaphragm or piece ofsponge, may be used. In addition, such bushings may be provided anywherealong the length of the cannula. However, if the bushing is provided atthe proximal end, it is preferable that a close fit between theinstrument and the stabilizer also be provided at the distal end.Moreover, an instrument stabilizer may be provided which includes onlyone of the stabilized disc and the close fit bushing without the other.

Turning now to FIGS. 49 and 50, a stabilizer swivel 1700 according tothe invention is shown. The stabilizer swivel, as described furtherbelow, permits an instrument stabilizer, such as stabilizer 1100, to bemaintained at an angle relative to a location on the body of a patient.The stabilizer swivel 1700 includes upper and lower complementary wedgeelements 1702, 1704, respectively, together preferably defining acylinder, and a disc 1720.

The upper wedge element 1702 includes: an upper surface 1705 providedwith a tubular mating portion 1706 defining an opening 1707 throughelement 1702, a lower surface 1711 including a circular recess 1708having a periphery 1709, and three threaded bores 1710 spaced about theopening 1707 and extending into the recessed portion of the upper wedgein a direction preferably normal to the surface 1712 of the recess 1708.The upper surface 1705 and lower surface 1711 are preferably at anapproximately 22.5° angle relative to each other. In addition, a lockingscrew 1714 extends through the upper wedge in a direction preferablynormal to the upper surface 1705 of the upper wedge.

The lower wedge 1704 includes: an upper surface 1715, a lower surface1716, a central opening 1717 which is preferably relatively larger thanthe opening 1707, and three threaded bores 1718 extending into the lowerwedge preferably normal to the upper surface 1715 of the lower wedge andpreferably equally spaced apart about the opening 1717. The uppersurface 1715 and the lower surface 1716 of the lower wedge element arepreferably at an approximately 22.5° relative to each other.

The disc 1720 includes a circumferential bevel 1722 on one side andthree holes 1724. The disc 1720 is provided in the recess 1708 betweenthe upper and lower wedges 1702, 1704. Preferably three screws 1726,each having a tapered and substantially flat head 1728, are engaged inthe three threaded bores 1718, with the taper of the head of the screws1726 lying complementary to the bevel 1722 on the disc 1720 such thatthe screws 1726 surround and retain the disc while still permitting thedisc to rotate relative to the lower wedge 1704. A second set of screws1730 extend up through the holes 1724 of the disc and secure the disc inthe recess 1708 of the upper wedge 1702. The disc 1720 and periphery1709 of the recess together define a track through which the heads 1728of the screws 1726 may be rotated. As such, the upper and lower wedgesare coupled to each other and are also permitted to rotate relative toeach other such that the tubular mating portion 1706 may be directed atvarious angles relative to the central opening 1717 of the lower wedge1704 (FIGS. 51 and 52), and therefore the surface on which the lowerwedge is seated. With the given angles of the surfaces of the upper andlower wedges, the tubular mating portion may be directed between 0° and45° relative to the opening of the lower wedge. It will be appreciatedthat by providing other relative angles to the respective upper andlower surfaces, a different range of angles at which the mating portionmay be directed is obtained. Other mechanisms permitting relativerotational configurations of the upper and lower wedges may also beused.

Referring to FIG. 52, the central opening 1717 is sized such that evenwhen a maximum angle is provided between the mating portion 1706 and thecentral opening, the pathway through the mating portion is unobstructedat preferably all locations, as indicated by arrow A. Once a desiredrelative angle is provided, the locking screw 1714 is tightened in tocontact with the lower wedge, thereby causing the upper and lower wedgesto be forced apart at one side and resulting in sufficient resistance torotation at the opposite side. Loosening of the locking screw 1714 againpermits relative rotation of the upper and lower wedges 1702, 1704.

Turning now to FIG. 53, an instrument stabilizer, e.g., stabilizer 1100,may be coupled to the stabilizer swivel 1700 at the tubular matingportion 1706. The stabilizer 1100 may then be angled relative to thesurface on which the stabilizer swivel is seated, i.e., the patient, tofacilitate maintaining the stabilizer, and therefore an instrumentextending therethrough, at a desired orientation. Moreover, it will beappreciated that the swivel 1700 can be integrated into an instrumentstabilizer such that the two are in a common instrument.

According to a preferred method which utilizes the system, a port deviceis stably positioned, e.g. clamped, in the chest wall and directed asnecessary for operation on the heart wall. A heart stabilizer is coupledto the port, and operated to apply a compressive force against the heartwall surrounding a location of the required bypass such that thelocation is substantially immobilized. An instrument stabilizer isinserted through a puncture hole in the chest cavity, and the distal tipof the cannula of the stabilizer is located adjacent to the surgicalsite. A first surgical instrument, e.g., a scalpel or needle holder, ispassed through the cannula and operated to perform at least a portion ofthe procedure. If other surgical instruments are required, the firstinstrument may be removed and other instruments may be extendedtherethrough. Alternatively, an instrument stabilizer may be providedfor each instrument. Once the bypass procedure is complete, theinstruments and instrument stabilizers are removed from the locus of thesurgery, and the heart stabilizer is also removed through its port.Then, the clamping forces on the port is loosened and the port iswithdrawn from the chest wall. Finally, the incision and puncture holesin which the port and instrument stabilizer were located are closed.This method eliminates the need for many-open heart procedures, as wellas the need to stop the heart.

There have been described and illustrated herein several embodiments ofa system for performing port off-pump coronary artery bypass surgery anda port device and heart stabilizer therefor. While particularembodiments of the invention have been described, it is not intendedthat the invention be limited thereto, as it is intended that theinvention be as broad in scope as the art will allow and that thespecification be read likewise. Therefore, while the elements of thesystem have been particularly described for use in a port off-pumpcoronary artery bypass procedure, it will be appreciated that eachelement may be used alone or in combination for other procedures. Inaddition, while the port and instrument stabilizer have been describedwith respect to their use with endoscopic instruments, each may be usedwith other types of surgical instruments. It will therefore beappreciated by those skilled in the art that yet other modificationscould be made to the provided invention without deviating from itsspirit and scope as claimed.

What is claimed is:
 1. A method of performing a port off-pump beatingheart coronary artery bypass surgical procedure through a chest wall,comprising: a) inserting a first port device into the chest wall; and b)extending a heart stabilizer through said first port device and lockingsaid heart stabilizer to said first port device such that sufficientpressure is applied to a beating heart wall surrounding a location ofthe required bypass such that the location is substantially immobilized.2. A method according to claim 1, further comprising: c) inserting asecond port device into the chest wall; and d) extending a surgicalinstrument through said second port device.
 3. A method according toclaim 2, further comprising: e) prior to extending said surgicalinstrument through said second port device, extending an instrumentstabilizer having a tubular portion through said second port device,wherein when said surgical instrument is extended through said secondport device, said surgical instrument is also extended through saidtubular portion of said instrument stabilizer, said instrumentstabilizer adapted to provide a damping force to said surgicalinstrument to reduce extraneous movement at a distal end of saidsurgical instrument.
 4. A method according to claim 3, furthercomprising: f) using said surgical instrument to at least partly performa coronary artery bypass procedure.
 5. A method according to claim 2,further comprising: e) rigidly fixing at least one of said first portdevice and said second port device to the chest wall.
 6. A methodaccording to claim 5, further comprising: f) angularly directing atleast one of said first port device and said second port device relativeto the chest wall.
 7. A method according to claim 2, further comprising:e) angularly directing at least one of said first port device and saidsecond port device relative to the chest wall.
 8. A method according toclaim 1, further comprising: c) extending at least a portion of acannula of an instrument stabilizer through tissue of the patient andinto a chest cavity; and d) extending a surgical instrument through saidcannula of said instrument stabilizer, wherein said instrumentstabilizer is adapted to provide a damping force to said surgicalinstrument to reduce extraneous movement at a distal end of saidsurgical instrument.
 9. A method according to claim 8, wherein: saidextraneous movement reduced is longitudinal relative to said cannula.10. A method according to claim 8, wherein: said extraneous movementreduced is non-parallel relative to said cannula.
 11. A method accordingto claim 8, wherein: said cannula is provided with a distal boring tipadapted to puncture the tissue of the patient thereby permitting theextension of said at least said portion of said cannula through thetissue.
 12. A method according to claim 8, further comprising: e) usingsaid surgical instrument to at least partly perform a coronary arterybypass procedure.
 13. A method according to claim 8, further comprising:e) coupling said instrument to the patient with sutures or adhesive. 14.A method of performing a port off-pump beating heart coronary arterybypass surgical procedure through a chest wall, comprising: a) insertinga first port device into the chest wall; b) clamping the first portdevice about the chest wall; and c) extending a heart stabilizer throughsaid first port device and locking said heart stabilizer to said firstport device such that sufficient pressure is applied to a beating heartwall surrounding a location of the required bypass such that thelocation is substantially immobilized.
 15. A method according to claim14, further comprising: d) inserting a second port device into the chestwall; and e) extending a surgical instrument through said second portdevice.
 16. A method according to claim 15, further comprising: f) priorto extending said surgical instrument through said second port device,extending an instrument stabilizer having a tubular portion through saidsecond port device, wherein when said surgical instrument is extendedthrough said second port device, said surgical instrument is alsoextended through said tubular portion of said instrument stabilizer,said instrument stabilizer adapted to provide a damping force to saidsurgical instrument to reduce extraneous movement at a distal end ofsaid surgical instrument.
 17. A method according to claim 16, furthercomprising: g) using said surgical instrument to at least partly performa coronary artery bypass procedure.
 18. A method according to claim 15,further comprising: f) angularly directing at least one of said firstport device and said second port device relative to the chest wall; andg) fixing said at least one of said first port device and said secondport device to the chest wall at a first angle which is oblique relativeto a normal of the chest wall at a location of the chest wall at whichsaid at least one of said first port device and said second port deviceis located.
 19. A method according to claim 14, wherein: said clampingoccurs about at least one rib.
 20. A method according to claim 14,further comprising: d) prior to said clamping, angularly directing saidfirst port device relative to the chest wall.